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Prosthetic Heart Valves Treatment & Management

  • Author: Eric M Kardon, MD, FACEP; Chief Editor: Richard A Lange, MD, MBA  more...
 
Updated: Feb 18, 2015
 

Emergency Department Care

In patients with acute valvular failure, diagnostic studies must be performed simultaneously with resuscitative efforts.

Primary valve failure

Patients with valvular failure due to breakage or abrupt tearing of the components usually present with acute hemodynamic deterioration. They need emergent valve replacement. Adjunctive therapy may be initiated while these arrangements are being made. A less dramatic presentation of valvular failure may be seen in patients with valve thrombosis or in those with more gradual deterioration of bioprosthetic valves (see Thromboembolic complications).

Begin afterload reduction and inotropic support in order to reduce the impedance to forward flow and improve peripheral perfusion. If the mean arterial pressure is higher than 70 mm Hg, sodium nitroprusside may be used. If the mean arterial pressure is lower than 70 mm Hg, dobutamine alone or in combination with inamrinone may be used.

Avoid inotropic agents with vasoconstricting properties.

Intra-aortic balloon counterpulsation may be useful in cases of acute mitral regurgitation when the patient is in extremis and surgical facilities are not immediately available. Intra-aortic balloon counterpulsation is relatively contraindicated in the presence of an incompetent aortic valve.

Prosthetic valve endocarditis

Administer intravenous antibiotics as soon as 2 sets of blood cultures are drawn. Vancomycin and gentamicin may be used empirically pending blood cultures and determination of methicillin resistance.

Patients taking warfarin who develop PVE should stop until CNS involvement is ruled out and invasive procedures are determined to be unnecessary.[5]

Consider anticoagulation in PVE, since the incidence of systemic embolization is as high as 40%.

Consider emergency surgery in patients with moderate-to-severe heart failure or in patients with an unstable prosthesis noted on echocardiography or fluoroscopy.

Thromboembolic complications

Patients presenting with embolization need to be anticoagulated if they are not already taking anticoagulants or have a subtherapeutic INR.

Assessment of valve function is needed.

The RE-ALIGN trial evaluated the safety and efficacy of dabigatran in patients with bileaflet mechanical prosthetic heart valves (recently implanted or implanted more than 3 months prior to enrollment). Patients were randomized to dose-adjusted warfarin or dabigatran 150, 220, or 300 mg BID. The study was terminated early due to the occurrence of significantly more thromboembolic events and excessive major bleeding with dabigatran compared with warfarin. These data resulted in revision of the US dabigatran prescribing information to include a contraindication in patients with mechanical prosthetic valves.[6]

Prosthetic valve thrombosis

Note the following:

  • Surgery had historically been the mainstay of treatment but is associated with a high mortality rate.
  • Mortality rates of 18% have been reported in those with New York Heart Association (NYHA) class IV undergoing surgery for left-sided prosthetic valve thrombosis.
  • Thrombolytic therapy may be used to treat select patients with thrombosed prosthetic valves.
  • Thrombolytic therapy is currently recommended over surgery for right-sided prosthetic valve thrombosis. [5]
  • Thrombolytic therapy is recommended over surgery for small left-sided prosthetic valve thrombosis (thrombus area < 0.8 cm 2). The use of heparin and serial echocardiography is also recommended in these cases to documents improvement and thrombus resolution. [5]
  • Thrombolytic therapy is recommended in large (=0.8 cm 2) left-sided prosthetic valve thrombosis when contraindications to surgery are present. [5]
  • Contraindications to thrombolysis of left-sided prosthetic valve thrombosis include the presence of a large left atrial thrombus, ischemic CVA between 4 hours and 4-6 weeks ago, and very early postoperative state (< 4 d). [20]
  • Thrombolytic therapy should always be done in conjunction with cardiovascular surgical consultation.
  • Patients with major anticoagulant-related hemorrhage require reversal of their anticoagulation with fresh frozen plasma and vitamin K.
  • The time off anticoagulants should be as short as possible to avoid valve thrombosis.
  • Use of recombinant factor VIIa or prothrombin complex concentrate should not be used to reverse excessive anticoagulation in patients with prosthetic heart valves.

Based on findings from a retrospective study of 778 patients, Yaffee et al recommend extending established guidelines for blood conservation strategy (BCS) in routine cardiac surgeries to aortic valve replacement.[21, 22] The investigators reported that implementing BCS (eg, limits on intraoperative hemodilution, tolerance of perioperative anemia, blood management education of the cardiac surgery team) may reduce the use of red blood cells (RBCs) during surgery—without increasing mortality or morbidity.[21, 22]

In their study, implementation of the strategy resulted in a 2.7-fold reduction in RBC transfusions as well as a 1.7-fold reduction in the incidence of major complications (eg, sepsis, respiratory failure, renal failure, death).[21, 22] The incidence of RBC transfusion fell significantly from 82.9% before use of BCS to 68.0% after implementation of the strategy.

Transfusion of 2 or more units of RBC on the day of surgery was associated with mortality, prolonged intubation, postoperative renal failure, and an increased incidence of any complication. Factors that affected the risk of RBC transfusion included the following[21, 22] :

  • Decreased risk: Isolated aortic valve replacement, minimally invasive approach, BCS
  • Increased risk: Older age, previous cardiac procedure, female sex, smaller body surface area
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Consultations

In patients presenting with any degree of prosthetic valvular failure, early consultation with a cardiologist is recommended in order to perform and interpret an echocardiogram.

Consult a cardiothoracic surgeon early in cases of severe hemodynamic compromise.

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Contributor Information and Disclosures
Author

Eric M Kardon, MD, FACEP Attending Emergency Physician, Georgia Emergency Medicine Specialists; Physician, Division of Emergency Medicine, Athens Regional Medical Center

Eric M Kardon, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Medical Association of Georgia

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

A Antoine Kazzi, MD Deputy Chief of Staff, American University of Beirut Medical Center; Associate Professor, Department of Emergency Medicine, American University of Beirut, Lebanon

A Antoine Kazzi, MD is a member of the following medical societies: American Academy of Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Richard A Lange, MD, MBA President, Texas Tech University Health Sciences Center, Dean, Paul L Foster School of Medicine

Richard A Lange, MD, MBA is a member of the following medical societies: Alpha Omega Alpha, American College of Cardiology, American Heart Association, Association of Subspecialty Professors

Disclosure: Nothing to disclose.

Acknowledgements

Mary C Mancini, MD, PhD

Professor and Chief of Cardiothoracic Surgery, Department of Surgery, Louisiana State University School of Medicine in Shreveport

Mary C Mancini, MD, PhD is a member of the following medical societies: American Association for Thoracic Surgery, American College of Surgeons, American Surgical Association, Phi Beta Kappa, and Society of Thoracic Surgeons

Disclosure: Nothing to disclose.

Judy Lin, MD

Disclosure: Nothing to disclose.

References
  1. Chiang YP, Chikwe J, Moskowitz AJ, Itagaki S, Adams DH, Egorova NN. Survival and long-term outcomes following bioprosthetic vs mechanical aortic valve replacement in patients aged 50 to 69 years. JAMA. 2014 Oct 1. 312(13):1323-9. [Medline].

  2. O'Riordan M. Survival and stroke rates equivalent at 15 years with mechanical and bioprosthetic aortic valves. Heartwire. September 30, 2014. [Full Text].

  3. O’Riordan M. SCCT policy statement recommends CT prior to TAVI/TAVR procedures. Medscape Medical News. Jan 11, 2013. [Full Text].

  4. Achenbach S, Delgado V, Hausleiter J, Schoenhagen P, Min JK, Leipsic JA. SCCT expert consensus document on computed tomography imaging before transcatheter aortic valve implantation (TAVI)/transcatheter aortic valve replacement (TAVR). J Cardiovasc Comput Tomogr. 2012 Nov. 6(6):366-80. [Medline].

  5. Whitlock RP, Sun JC, Fremes SE, Rubens FD, Teoh KH,. Antithrombotic and thrombolytic therapy for valvular disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012 Feb. 141(2 Suppl):e576S-600S. [Medline].

  6. Van de Werf F, Brueckmann M, Connolly SJ, Friedman J, Granger CB, Härtter S, et al. A comparison of dabigatran etexilate with warfarin in patients with mechanical heart valves: THE Randomized, phase II study to evaluate the safety and pharmacokinetics of oral dabigatran etexilate in patients after heart valve replacement (RE-ALIGN). Am Heart J. 2012 Jun. 163(6):931-937.e1. [Medline].

  7. Rahimtoola SH. Choice of prosthetic heart valve in adults an update. J Am Coll Cardiol. 2010 Jun 1. 55(22):2413-26. [Medline].

  8. Pibarot P, Dumesnil JG. Prosthetic heart valves: selection of the optimal prosthesis and long-term management. Circulation. 2009 Feb 24. 119(7):1034-48. [Medline].

  9. [Guideline] Bonow RO, Carabello BA, Chatterjee K, et al for the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. 2008 focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to revise the 1998 guidelines for the management of patients with valvular heart disease). Endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. J Am Coll Cardiol. 2008 Sep 23. 52(13):e1-142. [Medline]. [Full Text].

  10. Hammermeister K, Sethi GK, Henderson WG, Grover FL, Oprian C, Rahimtoola SH. Outcomes 15 years after valve replacement with a mechanical versus a bioprosthetic valve: final report of the Veterans Affairs randomized trial. J Am Coll Cardiol. 2000 Oct. 36(4):1152-8. [Medline].

  11. Oxenham H, Bloomfield P, Wheatley DJ, et al. Twenty year comparison of a Bjork-Shiley mechanical heart valve with porcine bioprostheses. Heart. 2003 Jul. 89(7):715-21. [Medline]. [Full Text].

  12. Bates MG, Matthews IG, Fazal IA, Turley AJ. Postoperative permanent pacemaker implantation in patients undergoing trans-catheter aortic valve implantation: what is the incidence and are there any predicting factors?. Interact Cardiovasc Thorac Surg. 2011 Feb. 12(2):243-53. [Medline].

  13. Habib G, Thuny F, Avierinos JF. Prosthetic valve endocarditis: current approach and therapeutic options. Prog Cardiovasc Dis. 2008 Jan-Feb. 50(4):274-81. [Medline].

  14. Nataloni M, Pergolini M, Rescigno G, Mocchegiani R. Prosthetic valve endocarditis. J Cardiovasc Med (Hagerstown). 2010 Dec. 11(12):869-83. [Medline].

  15. Akhtar RP, Abid AR, Zafar H, Khan JS. Aniticoagulation in patients following prosthetic heart valve replacement. Ann Thorac Cardiovasc Surg. 2009 Feb. 15(1):10-7. [Medline].

  16. Daniels PR, McBane RD, Litin SC, Ward SA, Hodge DO, Dowling NF, et al. Peri-procedural anticoagulation management of mechanical prosthetic heart valve patients. Thromb Res. 2009 Feb 19. [Medline].

  17. Botta L, Bechan R, Yilmaz A, Di Bartolomeo R. Prosthetic valve endocarditis due to Brucella: successful outcome with a combined strategy. J Cardiovasc Med (Hagerstown). 2009 Mar. 10(3):257-8. [Medline].

  18. Jeejeebhoy FM. Prosthetic heart valves and management during pregnancy. Can Fam Physician. 2009 Feb. 55(2):155-7. [Medline].

  19. Shapira Y, Vaturi M, Sagie A. Hemolysis associated with prosthetic heart valves: a review. Cardiol Rev. 2009 May-Jun. 17(3):121-4. [Medline].

  20. Lengyel M. Diagnosis and treatment of left-sided prosthetic valve thrombosis. Expert Rev Cardiovasc Ther. 2008 Jan. 6(1):85-93. [Medline].

  21. Yaffee DW, Smith DE 3rd, Ursomanno PA, et al. Management of blood transfusion in aortic valve surgery: impact of a blood conservation strategy. Ann Thorac Surg. 2013 Nov 19. [Medline].

  22. Janeczko LL. Blood conservation strategy helpful in aortic valve replacement. Reuters Health Information. December 16, 2013. [Full Text].

  23. Brennan JM, Edwards FH, Zhao Y, et al. Early anticoagulation of bioprosthetic aortic valves in older patients: results from the Society of Thoracic Surgeons Adult Cardiac Surgery National Database. J Am Coll Cardiol. 2012 Sep 11. 60(11):971-7. [Medline].

  24. [Guideline] Wilson W, Taubert KA, Gewitz M, et al. Prevention of infective endocarditis: guidelines from the American Heart Association: a guideline from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group. Circulation. 2007 Oct 9. 116(15):1736-54. [Medline].

  25. Nishimura RA, Carabello BA, Faxon DP, et al. ACC/AHA 2008 guideline update on valvular heart disease: focused update on infective endocarditis: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Catheter Cardiovasc Interv. 2008 Sep 1. 72(3):E1-12. [Medline].

  26. [Guideline] Horstkotte D, Follath F, Gutschik E, Lengyel M, Oto A, Pavie A, et al. Guidelines on prevention, diagnosis and treatment of infective endocarditis. The Task Force on Infective Endocarditis of the European Society of Cardiology. France: European Society of Cardiology. 2004. [Full Text].

  27. American College of Obstetricians and Gynecologists. ACOG Committee Opinion: safety of Lovenox in pregnancy. Obstet Gynecol. 2002 Oct. 100(4):845-6. [Medline].

  28. Baddour LM, Wilson WR, Bayer AS. Infective endocarditis: diagnosis, antimicrobial therapy, and management of complications. Circulation. 2005 Jun 14. 111(23):e394-434. [Medline].

  29. Bussey HI. An overview of anticoagulants, antiplatelet agents, and the combination in patients with mechanical heart valves. J Heart Valve Dis. 2004 May. 13(3):319-24. [Medline].

  30. Butany J, Ahluwalia MS, Munroe C, et al. Mechanical heart valve prostheses: identification and evaluation (erratum). Cardiovasc Pathol. 2003 Nov-Dec. 12(6):322-44. [Medline].

  31. Butany J, Fayet C, Ahluwalia MS, et al. Biological replacement heart valves. Identification and evaluation. Cardiovasc Pathol. 2003 May-Jun. 12(3):119-39. [Medline].

  32. Cannegieter SC, Rosendaal FR, Briet E. Thromboembolic and bleeding complications in patients with mechanical heart valve prostheses. Circulation. 1994 Feb. 89(2):635-41. [Medline].

  33. [Guideline] Dajani AS, Taubert KA, Wilson W, et al. Prevention of bacterial endocarditis. Recommendations by the American Heart Association. Circulation. 1997 Jul 1. 96(1):358-66. [Medline].

  34. Das M, Twomey D, Al Khaddour A, Dunning J. Is thrombolysis or surgery the best option for acute prosthetic valve thrombosis?. Interact Cardiovasc Thorac Surg. 2007 Dec. 6(6):806-11. [Medline].

  35. Goldman ME. Echocardiographic doppler evaluation of prosthetic valve function and dysfunction. Adv Cardiol. 2004. 41:179-84. [Medline].

  36. Kahn S. Long-term outcomes with mechanical and tissue valves. J Heart Valve Dis. 2002. 11, Suppl 1:S8-S14.

  37. [Guideline] Lengyel M, Fuster V, Keltai M, et al. Guidelines for management of left-sided prosthetic valve thrombosis: a role for thrombolytic therapy. Consensus Conference on Prosthetic Valve Thrombosis. J Am Coll Cardiol. 1997 Nov 15. 30(6):1521-6. [Medline].

  38. MacKenzie GS, Heinle SK. Echocardiography and Doppler assessment of prosthetic heart valves with transesophageal echocardiography. Crit Care Clin. 1996 Apr. 12(2):383-409. [Medline].

  39. Mehlman DJ. A pictorial and radiographic guide for identification of prosthetic heart valve devices. Prog Cardiovasc Dis. 1988 May-Jun. 30(6):441-64. [Medline].

  40. O'Riordan M. FDA Approves Medtronic's CoreValve for Inoperable Patients. Medscape [serial online]. Available at http://www.medscape.com/viewarticle/819376. Accessed: January 26, 2014.

  41. Piper C, Kprfer R, Horstkotte D. Prosthetic valve endocarditis. Heart. 2001 May. 85(5):590-3. [Medline].

  42. Roudaut R, Lafitte S, Roudaut MF, et al. Fibrinolysis of mechanical prosthetic valve thrombosis: a single-center study of 127 cases. J Am Coll Cardiol. 2003 Feb 19. 41(4):653-8. [Medline].

  43. Stein PD, Alpert JS, Bussey HI, et al. Antithrombotic therapy in patients with mechanical and biological prosthetic heart valves. Chest. 2001 Jan. 119(1 Suppl):220S-227S. [Medline].

  44. Vongpatanasin W, Hillis LD, Lange RA. Prosthetic heart valves. N Engl J Med. 1996 Aug 8. 335(6):407-16. [Medline].

  45. Willson A, Webb J. Transcatheter treatment approaches for aortic valve disease. Int J Cardiovasc Imaging. 2011 Dec. 27(8):1123-32. [Medline].

 
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Medtronic Hall mitral valve. Reproduced with permission from Medtronic, Inc.
The Hancock M.O. II aortic bioprosthesis (porcine). Reproduced with permission from Medtronic, Inc.
Starr-Edwards Silastic ball valve mitral Model 6120. Reproduced with permission from Baxter International, Inc.
Carpentier-Edwards Duralex mitral bioprosthesis (porcine). Reproduced with permission from Baxter International, Inc.
Carpentier-Edwards Perimount pericardial aortic bioprosthesis. Reproduced with permission from Baxter International, Inc.
St. Jude Medical mechanical heart valve. Photograph courtesy of St. Jude Medical, Inc. All rights reserved. St. Jude Medical is a registered trademark of St. Jude Medical, Inc.
Edwards Sapien transcatheter aortic valve.
 
 
 
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